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2. Bilateral Cleft Anatomy 19 BILATERAL CLEFT ANATOMY IS ATTACHED TO THE SINGLE CLEFT THE PREMAXILLA NORMALLY ROTATED OUTWARD MAXILLA ON ONE SIDE AND THIS ENTIRE COMPONENT IS THE CLEFT SIDE MAXILLA IN AN VARYING DEGREES FROM ASYMMETRICAL DIFFERENT DISTORTION DOUBLE CLEFTS PRESENT AN ENTIRELY CONFIGURA TION IN THE COMPLETE BILATERAL CLEFT THE PREMAXILLA IS UNATTACHED THREE WHICH TO EITHER MAXILLA THUS THERE ARE SEPARATE COMPONENTS IN THEIR DISTORTION THE MAXILLAE ARE MORE OR LESS SYMMETRICAL TWO WHILE THE ARE USUALLY EQUAL TO EACH OTHER IN SIZE AND POSITION FORWARD ITS IN CENTRAL PREMAXILLARY ELEMENT PROCEEDS ON OWN WITHIN ITSELF FOR DIFFERENT DEGREES BUT WITH SYMMETRY EXCEPT IJI POSSIBLE DEVIATION FRONTONASAL THE COMPLETE SEPARATION OF THE CENTRAL COMPONENT OF PROLABIUM AND PREMAXILLA FROM THE LATERAL MAXILLARY SEGMENTS THE VASCULAR ABNORMALLY INFLUENCES NOSE PHILTRUM MUSCULATURE AND OF ALL THREE ELEMENTS ITY NERVE SUPPLY GROWTH DEVELOPMENT WHERE THE CLEFT IS INCOMPLETE ON BOTH SIDES THE DEFORMITY IS LESS AND IS STILL SYMMETRICAL IN SUCH CASE THERE IS USUALLY MORE OR LESS INTACT ALVEOLUS AND LITTLE OR NO PROTRUSION OF THE PRE THE MAXILLA THE COLUMELLA IS LIKELY TO BE LONGER THAN IN COMPLETE CLEFT BUT NOT OF NORMAL LENGTH SOMETIMES SOMETIMES THE DEGREE OF CLEFT VARIES ON EACH SIDE SIDE THE INCOMPLETENESS SHOWS AS ONLY THE SLIGHTEST NOTCH ON ONE SIDE OR THERE CLEFT ON THE OPPOSITE AND HALFWAY OR THREEQUARTER ON THE CLEFT ONE SIDE AND AN INCOMPLETE ONE CAN BE COMPLETE ON OF THE EXASPERATING ASPECT OTHER WHICH CONDITION EXAGGERATES THE ROTATION OF THE IN THE AND NOSE BUT IN ASYMMETRY NOT ONLY LIP ONE SIDE HELPS THE EXISTENCE OF SOME ATTACHMENT ON PREMAXILLA OF THE THE UNINHIBITED CENTRAL PROJECTION OF COURSE TO CHECK PREMAXILLA WORKING DURING THE EVEN THE MOST MINOR UNILATERAL SYNECHIA CURB OF THE EXPLOSIVE PERIOD CAN SOME PRENATAL AND POSTNATAL REDUCING ITS PROTRUSION THRUST OF THE PREMAXILLA APPRECIABLY 11 IN THE 30S HERE IS CASE VEAU SKETCHED AND COMMENTED ON THIS SIMONARTS BAND THAT DEMONSTRATES MODEST RESTRAINT BY TINY 41 SIMONARTS BAND ENGLAND IN 1948 WHILE AT ROOKSDOWN HOUSE BASINGSROKE RESIDUAL SKIN BRIDGES SPAN 1949 LEARNED TO REFER TO CONGENITAL SIMONARTS BANDS HOLDS OF LIP CLEFTS AS NING THE UPPER PORTION SITNONARTZ BANDS IN RECENT YEARS WORTH LATER REFERRED TO THEM AS DISCOVER THE ORIGIN OF THIS MYS SEARCH HAS BEEN UNDERWAY TO II THESE IN 1976 TOM GIBSON INTRIGUED BY TERIOUS SOBRIQUET HAD GUSTAV SIMON IN HIS 1868 BOOK PRESENTED TERMS FOUND THAT AND FOR BILATERAL CLEFTS CHAPTER 13 II AN ADHESIONTYPE OPERATION MUST HAVE WRITTEN ABOUT DEDUCED THAT SOMEONE SUBSEQUENTLY THE TRANSVERSE BANDS OF THE BY CREATING OLO REPOSITIONING PREMAXILLA THIS WOULD BE AN BAND OF ARZT IN ROSTOCK OPERATIVE WOLFE MEANWHILE TURNED TO ANTHONY NOT CONGENITAL ONE FORWARDED TWO LEAD REFER AND HE TURNED TO SAM PRUZANSKY WHO LES SPONTANSJOURFLA ENCES SIMONART SUR AMPUTATIONS 20 ALSO ARCHIVES MLICALES JUNE 1846 PP 327330 DES CONNAISSANCES WITH THESE REFERENCES TONY 1846 112119 A4EDICALES BELGES BOOKS LIBRARIAN FRANCIS RICHARD WOLFE RARE WOLFE WROTE MEDICAL SCHOOL WHO OF MEDICINE HARVARD COUNTWAY LIBRARY ARTICLE THEN TONY WOLFE OF THE FIRST SIMONART SENT PHOTOCOPIES FOR INFORMATION ON MICHAEL MEESEN LIEGE WROTE HIS FRIEND NOTICE OBTAINED FROM BELGIAN REGISTRY SIMONART AND RECEIVED CILIEN THERE WAS MAN NAMED PIERREJOSEPH WHICH INDICATED IN THE OF BRUSSELS BORN AGREG6 AT UNIVERSITY SIMONART PROFESSOR 30 DIED WAVRE DECEMBER 19 1846 AGE WAVRE MAY 20 1816 OF DISCUSSING CASES SPONTANEOUS SIMONART HAD BEEN PREVIOUSLY OF THE EXTREMITIES DUE TO EN AND DEEP GROOVING AMPUTATIONS AMNIOTIC BANDS AFTER EITHER UMBILICAL CORD OR BY CIRCLEIRIENT BY AN THE LITERATURE HE MENTIONED THE CASES IN REVIEWING PREVIOUS IN BRUSSELS HERE OF LATERAL FACIAL CLEFT CASE SEEN INTERESTING TYPE LES SPON FROM HIS NOTES SUR AMPUTATIONS ARE EXCERPTS PAPER ET DE DES CONNAISSANCES M6DI CAES PRATIQUES TANS IN JOURNAL IN THE ORIGINAL JUNE 1846 PP 328329 PRESENTED FRENCH AND TRANSLATED INTO ENGLISH DE LA MARERNIT DE BRUXELLES CHEZ UN FETUS RECUEJILI II PEU TEMPS COMME DE IA COMMISSUTE LABIALE EST LA JONE DE CHAQUE C6T PARTIR REMONRE UNE BRIDE DE CETTE ESP QUI COUP DANS ROUTE SON 6PAISSEUR PAR VERS 1OCCIPUT THE CHEEK ON THE MATERNITE OF BRUSSELS IN FETUS OBTAINED NOT LONG AGO AT THICKNESS WAS CUT IN ALL ITS BY EACH SIDE FROM THE LABIAL COMMISSUTE EXTENDED TO THE OCCIPUT BAND OF THIS TYPE WHICH UP AMNIOTIC BANDS HE WHETHER THE LATER IN HIS ARTICLE QUERIED HE ALSO STATED INTRAUTERINE INFLAMMATORY PROCESSES REPRESENTED LA ET QUASI COUPS QUE MOLLES SOUSCUTANS SONT D6JA SEPAREES LES PATTIES AMINCISSEMENT INTACTE CELLECI NA SUBI QUUN LEGER PEAU RESTE ENCORE AND ALMOST DIVIDED THE SUBCUTANEOUS SOFT TISSUES ARE ALREADY SEPARATED THINNING IT HAS ONLY SLIGHT WITH THE SKIN REMAINING INTACT UNDERGONE DID INDEED REFER TO CONGENITAL THUS IT SEEMS THAT AS SIMONART AND CHEEK FROM THE LABIAL COMMISSURE SKIN BRIDGES IN THE AREA BANDS SOME THE THE NAME SIMONARTS TO THE OCCIPUT OVER YEARS THE RESIDUAL SKIN BRIDGES CROSSING HOW BECAME ASSOCIATED WITH OF CLEFTS UPPER PORTION LIP 21 AN ANATOMISTS DETAIL OF THE BILATERAL IN 1954 SUMMERFIELD KING DESCRIBED THE ANATOMY WITH THE NOSTRILS WHICH DEFORMITY AS TWO DEEP CLEFTS CONTINUOUS MEDIAN RUBERCLE FROM THE LATERAL ELEMENTS OF THE SEPARATE PAIRED THE HAS TWO BULGES CONTAINING THE UPPER LIP PREMAXILLA LARGE MEDIAN INCISOR TEETH AND THE BONE RELATED TO THEM NARROW THE TO THE IS RIDGE THE FRENULUM ATTACHING PREMAXILLA PROLABIUM FORMED OF CONNECTIVE TISSUE COVERED BY THICK UNCORNIFIED CONTINUES INTO STRATIFIED EPITHELIUM THE INFERIOR FRENULUM OF THE WITH FIBROUS BROAD VSHAPED RED LIP MARGIN PROLABIUM ITS HAS CONNECTIVC TISSUE VERY RICHLY VASCULARIZED EPITHELIUM THE RED THIN STRATUM CORNEUM WITHOUT GLANDS OR HAIRS BETWEEN THE THERE ON EITHER SIDE NARROW STRIP LIP MARGIN AND GUM LIES OF MUCOUS MEMBRANE WITH AN UNCORNIFIED TYPE OF STRATIFIED OF MODERATE THICKNESS AS EVERTED POSTERIOR EPITHELIUM REPRESENTED OF THE SULCUS BETWEEN SURFACE OF LIP THE EPITHELIUM PROLABIUM THINNER TO THE RED IN THE AND GUM IS SIMILAR BUT SUPERIOR MARGIN COVERED WITH SKIN PROLABIUM IS TRIANGULAR OR CIRCULAR AREA HAIRY THE NEAR THE RED LIP MARGIN MUCOCUTANEOUSJUNCTION ALTHOUGH STILL OF SKIN HAIRS ARE OR EPIRHELIUM IS CLEARLY ORDINARY TYPE SCANTY ABSENT THE MEDIAN RUBERCLE CONTAINS THE RIGHT AND LEFT PREMAXILLAE UNITED BY MEDIAN SUTURE EACH PREMAXILLA IS ENLARGED LATERALLY CENTRAL INCISOR INFEROLATERALLY TO CARRY TWO INCISOR TEETH LOOKING AND LATERAL INCISOR AT HIGHER LEVEL LOOKING POSREROLATERALLY TOOTH THEIR SOCKETS ARE SHALLOW GREAT PART OF THE ROOTS BEING COVERED ONLY WITH SOFT TISSUE EXTENSION FROM THE IS EXTENDING POSTERIORLY AS AN PREMAXILLAE WHICH IN THIS RESTS THE SUBVOMERINE PROCESS PRODUCES GROOVE THE NARROW VOMER THE CARTILAGINOUS NASAL SEPTUM AND LONG SHALLOW ALVEOLAR THE MAXILLA IS REPRESENTED ON EACH SIDE BY MILK TEETH AND FRONTAL AND PROCESS CONTAINING SOME BY PROCESS BUT THERE IS NO MAXILLO PAIR OF MINUTE PALARAL PROCESSES FOR THE BONES ARE PREMAXILLARY INCISIVE SUTURE WIDELY SEPARATED 22 LIP ANATOMY PROLABIUM SOFT TISSUE END OF THE FRONTONASAL THE PROLABIUM IS THE POINT IN SIZE FROM FEW MILLIMETERS TO OVER COMPONENT IT MAY VARY AND WIDTH IN BILATERAL CLEFT IT HAS BEEN CENTIMETER IN HEIGHT NO CUPIDS BOWNO PHILTRUM TRAGICALLY SHORTCHANGED POSSESSING COLUMNS AND NO LABIAL SULCUS AND IS ATTACHED DIMPLE NO PHILTRUM AND IS ALL THIS LITTLE OF TO LITTLE OR NO COLUMELLA THAT NOT PATCH THE FLAT SKIN AND MUCOSA IS LACKING SOFT PROLABIUM SITTING IS FORLORNLY ON THE FRONT OF THE UNRESTRAINED AGGRESSIVE PREMAXILLA EVIDENCE THAT MUSCLE MIGRATION FROM THE MAXILLARY PROCESSES NOT REINFORCED THIS MINIMAL BIT OF THE FRONTONASAL PROCESS MUSCLE DISCREPANCY AS NOTED INTERMITTENTLY BY MULLEN VEAU LEE BURIAN DAVIS STANEK KING STARK EHRMANN REES SWINYARD CONVERSE FARA SMAHEL LATHAM DUFFY AND OTHERS THERE SIMPLY ARE NO MUSCLE FIBERS IN THE PROLABIUM OF COMPLETE BILATERAL CLEFTS ALTHOUGH THEY OF MUSCLE ARE PLENTIFUL IN THE CHEEK AND OVER THE SIDE THE NOSE FIBERS ARE HOWEVER FOUND IN THE PROLABIUM OF INCOMPLETE BILAT ERAL CLEFTS AND THE AMOUNT VARIES INVERSELY WITH THE DEGREE OF THE CLEFTINGTHE LESS SEVERE THE CLEFT THE MORE MUSCLE IN THE PROLABIUM THESE FINDINGS SEEM COMPATIBLE WITH THE MESODERM MIGRATION AND MERGING THEORIES IN 1931 MULLEN EXPRESSED SUSPICION THAT THERE WAS NOT ANY MUSCLE AND IN 1946 LEE DOCUMENTED THE ABSENCE OF MUSCLE IN THE PROLABIUM IN 1958 STARK AND EHRMANN RECOGNIZED THAT THE PROLABIUM CONTAINED NORMAL MESODERM BUT WITHOUT MUSCLE IT IS INTERESTING HOW MOD THOMAS REES SON OF MORMON IN PROFESSOR OF BIOLOGY AT THE UNIVERSITY OF UTAH GOT INTERESTED THE MUSCLE OF THE PROLABIUM ABOUT 1955 WHILE TRAINING WITH MCLNDOE AT EAST GRINSTEAD REES OPERATED ON 15YEAROLD IRISH BOY WITH COMPLETE BILATERAL CLEFT THE PROLABIUM WAS SO ATTEN UATED THAT HE USED IT FOR COLUMELLA NOTING ITS ABSENCE OF MUSCLE THE FOLLOWING YEAR MCLNDOE TOOK REES WITH HIM TO HIS GREAT WHEAT FARM ON THE NORTHERN SLOPE OF KILIMANJARO EAST AFRICA AND AND MICHAEL STARTED DURING THIS TRIP MCLNDOE REES WOOD THOMAS REES 23 PLAN THAT WAS LATER TO DEVELOP INTO THE FLYING DOCTORS OF EAST AFRICA DURING OTHER TRIPS TO AFRICA REES OPERATED ON TWO OTHER ADULT BILATERAL CLEFTS WITH ATTENUATED PROLABIUMS AS HE WROTE RECENTLY THESE THREE CASES LATER STIMULATED ME TO LOOK INTO THE PROHIEM OF MUSCLE IN THE PROLABIUM IN 1962 WITH SWINYARD AND CONVERSE HE REPORTED ELECTRO MYOGRAPHIC EVIDENCE OF ABSENCE OF MUSCLE ACTIVITY IN THE PROLABIUM HISTOLOGICAL PICTURE IN 1967 FARA AND SMAHEL MADE SOME DEDUCTIONS FROM THE STUDY OF 330 CASES OF COMPLETE BILATERAL CLEFT LIPS OPERATED ON
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